Fig. 1: Overview of this study.

Consecutive PsAF patients were prospectively enrolled in this study. LGE-MRI images were acquired prior to the ablation procedure (light-blue panel), which served as the basis for the generation of personalized bi-atrial DTs that incorporated the patient-specific fibrosis distribution (light-green panel). Following the substrate inducibility test, LRs were identified (reentrant activation shown with arrow in light-magenta panel). Next, IO-PVI, WA-PVI and PWI + PVI ablation strategies were executed virtually in each DT, and their efficacy on diminishing the arrhythmogenic propensity of the LA substrate was quantified. During each ablation procedure (bottom row), EAM data in sinus rhythm was acquired to investigate the presence of LVA (light-purple panel) and examine whether LVAs can be predictors of the benefit of the PWI + PVI strategy. Finally, these features of fibrotic substrate were utilized to stratify patients benefitting from each ablation strategy. DT digital twin, EAM electro-anatomical map, IO-PVI individual ostial PVI, LA left atrial, LGE-MRI late gadolinium enhancement-magnetic resonance imaging, LR location of reentry, LVA low-voltage area, PsAF persistent atrial fibrillation, PVI pulmonary vein isolation, PWI + PVI left atrial posterior wall isolation plus WA-PVI, WA-PVI wide antral PVI.